MEDICARE: EDGAR P POREMBA DDS MSD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	105719	CO

General Provider Information

NPI Number	:	1982758173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGAR P POREMBA DDS MSD PC

Provider Business Mailing Address
First Line	:	2997 BROADMOOR VALLEY RD
Second Line	:
City	:	COLORADO SPGS
State	:	CO
Zip	:	80906-4405
Country	:	US
Telephone Number	:	719-576-0149
Fax Number	:	719-579-5373

Provider Business Practice Location Address
First Line	:	2997 BROADMOOR VALLEY RD
Second Line	:
City	:	COLORADO SPGS
State	:	CO
Zip	:	80906-4405
Country	:	US
Telephone Number	:	719-576-0149
Fax Number	:	719-579-5373

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. EDGAR P POREMBA
Credential	:	DDS MSD
Telephone Number	:	719-576-0149

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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